Tag Archives: Substance Abuse & Addictions

Substance Abuse & Addictions

Standing in the shadow of addiction

By Lindsey Phillips October 30, 2018

Theresa Eschmann, a licensed professional counselor (LPC) and addiction family specialist in private practice in St. Louis, experienced firsthand the power of denial in adult children of parents with alcohol use disorders. All her life, Eschmann had witnessed her mother struggle with this disorder, yet upon finding her mother dead with a bottle of alcohol in her hand, Eschmann’s first response was denial. She couldn’t believe that her mother’s alcohol use disorder had caused her death, initially insisting that someone must have poisoned her.

“I … took a chemical dependency proficiency certification to try to get some understanding of what killed her because it couldn’t have just been alcohol,” Eschmann says, explaining her thinking at the time. “Alcohol made you sick. It made you have delirium tremens. It made you see things. But it couldn’t have killed you.”

Denial is often a strong coping mechanism for adult children of parents with alcohol use disorders, says Lisa Kruger, an LPC and psychotherapist and the owner of Stepping Stone Psychotherapy in the Washington, D.C., metro area. “They have to deny any feelings of sadness or anger that they might have in order to survive,” she says.

This denial extends to adult children’s own potential struggles with substance use disorders. Keith Klostermann, an assistant professor in the Department of Counseling and Clinical Psychology and the director of clinical training for the marriage and family therapy program at Medaille College, had a female client whose father chronically abused alcohol, and her own drinking often led to fights with her boyfriend. One of these drunken fights resulted in her breaking her foot. Even so, she maintained a permissive attitude toward drinking and brushed it off as a recreational activity.

The client was firmly in denial and not yet ready to address either her experience of growing up around substance abuse issues or her own drinking habits, says Klostermann, a licensed marriage and family therapist and licensed mental health counselor who maintains an active practice in New York. Counselors may be eager to push clients to explore these issues, but Klostermann warns that discussing the implications of this childhood experience before clients are ready is a recipe for disaster. Taking that approach may lead to problems establishing a therapeutic alliance or cause clients to end counseling prematurely, he explains. Instead, he advises, counselors can help clients connect the dots and arrive at an understanding that their behavior makes sense based on their experiences growing up.

Asking the right questions

Being an adult child of a parent with a substance use disorder is not uncommon. According to the National Association for Children of Addiction, 1 in 4 children in the United States (or approximately 18.25 million children) live in a family with a parent who is addicted to drugs or alcohol. Yet, Eschmann, a certified master addiction counselor and a member of the American Counseling Association, says it’s her sense that asking whether clients grew up in homes where addiction was present is often skipped over in clinical assessments.

In addition, because these individuals have frequently learned to minimize, discount or deny the implications of growing up in a home with substance abuse, they aren’t particularly likely to seek counseling for those issues.

Being a child of a parent who abused substances “may be the elephant in the room, but that may not be what brings them in. They may not recognize it,” says Klostermann, an ACA member. “The stuff that happens to us when we were younger, a lot of times we carry with us, [but] we don’t even realize why we do the stuff we do. We just sort of do it out of inertia.”

Klostermann and Kruger say that many of their clients present with relationship problems, anxiety, stress, depression and substance use. Often, the counselors note, these issues result from growing up with a parent who had a substance use disorder.

The environment of walking on eggshells around a parent who is under the influence of a substance creates and breeds anxiety for the child, Klostermann explains. When the child becomes an adult and engages in stressful situations in college (e.g., exams) or at work (e.g., deadlines), the person’s anxiety can snowball, he adds. Likewise, they may struggle with adversity and withdraw socially because they find it difficult to navigate relationships. This isolation can lead to depression, which is a real challenge, Klostermann says.

Counselors can look for possible warning signs that their adult clients were exposed to substance abuse issues in the home as children, Klostermann says. For instance, clients might engage in avoidant strategies (e.g., using alcohol as a way to cope with stress) or have a permissive attitude about substance use (e.g., “I don’t drink much. I only have a 12-pack a day.”).

Kruger, an ACA member who specializes in the areas of depression, anxiety, posttraumatic stress disorder, trauma and addiction, had a male client who came to see her for help with relationship issues and high anxiety. In his intake paperwork, the client wrote that he drank nightly, so she asked him how many drinks he had in a week. “It was 50 to 60 a week,” he replied, “but now it’s only 20 or 30.” This response was a big red flag, yet he didn’t realize that his drinking was a problem, she says.

To help clients recognize unhealthy behaviors, Kruger often uses motivational interviewing techniques. For example, with this client, a counselor might ask, “How is drinking 20 or 30 drinks a week working out for you?”

If counselors see potential warning signs, Klostermann advises asking questions about current substance use patterns, previous substance use, parental substance use and family attitudes around drinking. For example, counselors might ask the following questions: What was it like growing up in your home? What does drinking a lot or having a good time mean to you? What does that look like? What are the holidays and celebrations like in your family? What is a typical family dinner or birthday party like?

“Substance use is built around so many family functions and gatherings and celebrations,” Klostermann says. So, if a client comments, “My parents liked to party,” counselors could follow up by asking the client to explain what that means and what the implications are for the client’s life (e.g., increased violence after a parent drank, embarrassment when a parent became intoxicated at a social event). Klostermann explains that these types of questions help clinicians gain a better understanding of not just the acute nature of growing up in an environment with substance abuse but also the context of it — for instance, whether parental drug use led to a more permissive attitude at home or whether the child adopted unhealthy coping strategies.

In addition, adult children often find it easier to talk about others rather than themselves, Klostermann says. By asking these types of nonjudgmental questions (e.g., “Did drinking like that seem to work out for your mom?”), counselors can help clients create insight and awareness by changing the frame of reference, he explains. This technique helps clients gain an understanding about not only the severity of their parents’ alcohol or substance use but also the emotional implications of that behavior, he adds.

After counselors establish that awareness, Klostermann says, they can connect it to the client’s present situation (e.g., “Does drinking affect your relationships or grades?”). He suggests that counselors could also try to educate clients by saying something along the following lines: “Given what you described about your [parent’s] history, it’s not uncommon for people that grow up in these homes to sometimes exhibit certain behaviors. Sounds like that might be happening for you.”

Counselors are “planting the seed [and] leaving the door open but also helping [clients] to connect the dots and understand this is what’s going on and here’s why,” he explains.

In addition to asking about clients’ personal and family substance use histories, Kruger often focuses her questions on clients’ relationships with their parents. These questions can help bring out emotions such as shame, guilt or anxiety that stem from being a child of a parent with a substance use disorder, she says.

Emotional and attachment wounds

“Adult children of alcoholics … have difficulty identifying and expressing emotions,” Kruger explains, “because when they were kids, they had to set aside their own emotions — maybe they had to care for their parents. … They didn’t understand what their emotions were because what they saw in their parents’ relationship was inconsistent presentation or organization of emotions between them and maybe even between the parent and child too.”

To help clients who are having difficulty expressing their emotions, Kruger provides a sheet that shows 50 visual representations of emotions and asks clients to name the emotions that describe how they are feeling. She says this activity, which she refers to as an “emotional cheat sheet,” is “a good springboard … for clients who really don’t have the language [for their emotions].”

Kruger and Eschmann find that codependency is another common issue for adult children of parents with alcohol use disorders. Because these adult children grow up being sensitive to the needs of their parents — even to the point of ignoring their own needs — they often engage in approval seeking, which leads to codependency, Kruger explains. This need for approval and to avoid conflict can result in these individuals seeking acceptance from others who do not treat them well, which causes lower self-esteem, she says.

Often, clients who are codependent will assume they are OK because they are not the ones causing problems, Eschmann observes. She questions clients on codependent behavior by asking about their controlling behaviors, approval-seeking behaviors, anxiety, and distortion around intimacy and separation.

For Kruger, it all comes back to attachment — how bonds are created and broken. Parents who struggle with alcohol use disorders are typically inconsistent in their parenting and in their show of emotion toward their children. As she points out, this can create attachment wounds and be stressful for children growing up under these circumstances. Children may be doubly affected because they still depend on parents for care and for getting many of their emotional needs met. At the same time, these children often aren’t in a position to fight or to flee elsewhere, she adds.

Counselors can help adult clients gain awareness of how their current relationship patterns are affected by their childhood experiences, Kruger says. One technique she finds helpful involves taking the client’s experiences and imagining how those experiences would be perceived on The Brady Bunch. As a member of The Brady Bunch family, Kruger explains, the client would notice instantly if a partner or spouse were abusive because of the contrast with the sitcom family. However, growing up in a stressful environment with one or both parents suffering from an alcohol use disorder tends to distort a person’s perceptions of what is “normal” or acceptable.

For example, having a parent who drank and was inconsistently present when the client was a child would affect the client’s ability to evaluate his or her current relationships. If the client has a partner who sometimes withholds affection or emotion, is manipulative and comes around only when he or she wants something, the client won’t necessarily notice any red flags because those are the circumstances and relationship patterns the client knows from growing up, Kruger explains.

Kruger also gives short attachment assessments and finds that these clients often present with anxious attachments. “In relationships, [they cater] to the other person because that attachment anxiety comes up and that need for approval keeps them in relationships” — including bad ones, she says.

To help clients see the connection between their view of themselves and their relationships with others, Kruger will have clients write out how they view themselves, how they view other people and how they view the world. Then, they will discuss how these views are created, how clients are perpetuating these views and how they would like to see themselves in relationships.

The exercise is particularly helpful for clients who find themselves in toxic relationships, Kruger adds. “It’s really rare [for] somebody in a toxic relationship [who is] being manipulated to say, ‘I see myself in high regard, and I think I’m great.’ It’s usually the opposite,” she says.

Making meaning of conflicted feelings

Another crucial part of adult children’s recovery is sorting through their conflicted feelings of love, disappointment, anger and shame. In fact, both Eschmann and Kruger find that shame and guilt are common presenting issues.

Children often feel that a parent’s situation is their fault, and they find it difficult to process these multilayered emotions, Kruger notes. They simultaneously feel disappointment in and love for their parent. For adult children, processing and making sense of these feelings is a substantial part of recovery, she explains. Counselors should acknowledge that shame piece and how clients have “put that burden on themselves and carried that burden with them throughout adulthood,” Kruger advises. 

“Shames translates to I am bad,” Kruger points out. “Even if [clients] don’t present it on the outside, they’re usually coming in with some pretty damaged self-esteem and are already judging themselves.” In part for that reason, she emphasizes the importance of creating a nonjudgmental atmosphere in counseling.

When self-esteem, thoughts and feelings are involved, Kruger uses cognitive behavior therapy techniques. She says she has experienced a good deal of success with an exercise that blends cognitive restructuring and emotion identification. In the exercise, clients look at a triggering event and then identify their negative self-talk and automatic thought, the feeling that this thought creates, evidence to strengthen this thought, evidence against this thought and a new thought that they can believe.

The exercise allows clients to recognize their negative self-talk and its consequences and enables them to reconfigure these self-demeaning thoughts in a way that is believable to them, Kruger explains. For example, clients might think that they are “bad” and list all of the evidence they have for that thought. Next, they could counter that thought with the fact that they recently got a raise at work. Finally, they could create a new thought that sometimes they do good things, Kruger says.

“These clients need validation,” Eschmann emphasizes. “They didn’t get it growing up.” Instead, she explains, the parent who was abusing alcohol or other substances has often discounted the adult child’s feelings and experiences.

Klostermann also stresses the importance of normalizing these clients’ emotions and experiences. These clients may not realize — or, in some cases, perhaps don’t want to realize — the impact on them of their parents’ drug or alcohol use, he says. He notes how difficult it can be for clients to verbalize that their parents had or have a drinking problem, especially if they maintain a glorified version of their parents. For this reason, counselors need to help clients understand that it is possible for them to love their parents while still recognizing that their parents made mistakes.

Kathleen Brown-Rice, department chair and associate professor in the Department of Counselor Education at Sam Houston State University, agrees. Counselors must keep in mind that the family member is someone whom the client still loves and cares about, she says. Counselors can give clients the “space to say that you can love somebody and also be disappointed by their behaviors. You can love someone, and they can love you, and they can still hurt you,” she says. “[It’s] helpful for clients to understand that it’s more complicated than just [their parents are] bad or they don’t love [them].”

Eschmann helps clients focus on unresolved grief, which is common for adult children who grew up with parental substance abuse. Adult children are often hesitant to admit that their mom left them alone all night with a stranger or that their father came home drunk and had violent arguments with their mother, Eschmann says. They might not want to admit that these past events are why they get triggered today during certain situations.

“[Clients] have to accuse before [they] can excuse,” Eschmann asserts. “They have to go back and [ask], ‘What happened to me?’ This isn’t about [the parents] anymore. It’s about [the client].” If clients become more aware of what happened to them and what kind of environment they lived in that made them fearful and anxious today, then they can start healing, she adds. 

Mindful resilience 

Adult children who grew up in the same environment with substance abuse can respond very differently. One person may be angry, whereas another may be empathetic, and still another may end up also struggling with a substance use disorder. This raises the question of why some adult children of parents with alcohol use disorders are more resilient than others.

Resilience is “critical in terms of shaping kids’ development as they transcend into adulthood in terms of the choices that they make and the way that they deal with stress and conflict,” Klostermann points out. Based on his clinical experience, Klostermann suggests that having other healthy outlets (e.g., extracurricular activities such as sports, positive role models such as grandparents) and an ability to contextualize what is happening help to foster resilience.

Brown-Rice, an LPC and a member of ACA, acknowledges that there is more than simple genetics at play with resiliency. “Resiliency is not a moral characteristic. It’s a function of our brain,” she says. It’s “how our brain controls for those genetics … how that resiliency comes in and how we support that.”

Recently, she, along with Gina Forster (a lecturer in the Department of Anatomy at the University of Otago) and several other colleagues, conducted a study funded partly by a grant from the Center for Brain and Behavior Research at the University of South Dakota on college students who had similar experiences of being adult children of parents with substance use disorders. The participants identified as either engaging in risky substance use (the vulnerable group) or not engaging in risky substance use (the resilient group).

“Overall, their experience being raised by a parent who met the criteria for having a substance use disorder appeared similar,” says Brown-Rice, who presented the findings at the ACA 2017 Conference in San Francisco. However, “vulnerable individuals had lower scholastic performance … [and] reported poor overall psychological, physical and social health and more polysubstance use.”

The study also revealed another difference: The vulnerable group had a short allele of the serotonin transporter gene, which meant they were more likely to react to stressful events. “[This group] had a reduced uptake of their serotonin, which can increase depression and stressful life events,” explains Brown-Rice, associate editor of the Journal of Addictions & Offender Counseling.

Brown-Rice and the other researchers also measured brain activity while the participants viewed positive images (e.g., a cuddly bear), negative images (e.g., a crying baby) and neutral images (e.g., a chair). They found that the vulnerable group had altered brain activity when processing negative images. This group recognized the negative image but refused to store it, Brown-Rice explains.

Brown-Rice hypothesizes that this refusal to store negative images is an important factor in resiliency levels. To illustrate, imagine that you are walking outside and see a stick. Initially, your brain may think that the stick is a snake, so you jump back. As Brown-Rice explains, when you first see the stick, the amygdala activates and warns you because it looks like something that the brain remembers could hurt you. But after taking a closer look (i.e., storing the image), you realize it is just a stick, so you relax.

Resiliency depends on our ability to realize that the stick is not a snake. Some people, however, may be more likely because of brain functioning or genetic variations to see the stick and just react by running, Brown-Rice says. Thus, counselors can help certain clients by nurturing the parts of the brain that activate during stressful situations, she explains.

Brown-Rice incorporates this research into her clinical practice. She tells her clients that they have a resilient part of the brain — the prefrontal cortex — and that in session, they can work on controlling their brain and building their optimism and resiliency. She suggests that counselors use mindfulness techniques, such as guiding clients in breathing exercises and finding a safe place to go when triggered, because mindfulness is effective in calming the amygdala, which activates during stressful events.

Consistency also helps promote clients’ resiliency, Brown-Rice notes. If counselors are inconsistent, she says, that will put clients on edge.

Klostermann agrees. He finds that having a clear agenda helps to create a sense of safety and build rapport with clients. He informs them about his clinical approach and what to expect during the session and tells them there is no assumption on his part that they will schedule another appointment.

Kruger recommends using clients’ resiliency to help strengthen their internal sense of self. After all, she points out, adult children of parents with alcohol use disorders have already developed survival strategies, such as caring for siblings in areas in which the parent was lacking.

Instead of simply telling clients that they have strengths, Kruger uses motivational interviewing, which allows clients to identify and recognize their strengths themselves. For example, rather than telling a client, “You seem to be good at your job,” she might ask, “In what ways are you praised at your job?” This question helps clients reach the conclusion themselves, which builds their internal positive regard.

One more piece of advice for working with adult children of parents with substance use disorders: Counselors shouldn’t be afraid to change their approach if it’s not working. For example, Brown-Rice says, research has shown that people who have a short allele for serotonin may be resistant to cognitive behavior treatment. “If clients are not responding, we have to think maybe we need to change,” she says. “Maybe we need to move. Maybe we need to [incorporate] some of these mindfulness techniques. Maybe we need to do something else.”

Sometimes, it may be the counselor, not the client, who is being resistant, she stresses.

Halting the domino effect

The desire to get treatment for someone with a substance use disorder often overshadows the way that addiction affects the person’s family and others who care about the person. It shouldn’t.

In her educational video on addiction in the family, Claudia Black, an expert in addiction, highlights a child’s drawing of his experience living in a home where substance abuse is present. The child draws images of dominoes and writes, “Alcohol and drugs are like dominoes. They knock down the person, who knocks down everyone, including themselves.” The child’s words illustrate the way that addiction permeates and affects the entire family, not just the person with the substance use disorder.

For the first two years after her mother died from alcohol-related causes, Eschmann found herself crying repeatedly. Her grief and denial led her to learn more about chemical dependency, addiction and adult children of parents with alcohol use disorders. Counselors need to understand that the family has an emotional illness as well, Eschmann emphasizes. This illness is just as progressive as what the person with the substance use disorder is facing, she adds.

Brown-Rice reminds clients that they are not responsible for their substance use issues, but they are responsible for how they respond to these issues. For adult children of parents with substance use disorders, this means learning how their childhood experiences affect their current behaviors and choices.

Adult children of parents with substance use issues often feel isolated. Support groups such as Al-Anon and Adult Children of Alcoholics are helpful because they provide opportunities for people with similar experiences to share their stories and come to the realization that they’re not alone, Kruger says.

Counselors should also help clients understand that their parents’ substance use is not their shame to carry and substance abuse is not a legacy that they have to repeat, Brown-Rice says. Then, clients will realize that choosing a different path doesn’t mean that they are being disrespectful or dishonoring their parents, she explains.

The hope is that this different path will stop the domino effect of addiction, shame, depression and pain.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at consulting@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editorct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Group counseling with clients receiving medication-assisted treatment for substance use disorders

By Stephanie Maccombs September 6, 2018

Holistic care, or the integration of primary and behavioral health care along with other health care services, is becoming more common. In my experience as a mental health and chemical dependency counselor in an integrated care site, I have come to value the benefits that such wraparound services offer.

I now have the opportunity to consult with primary care providers, medication-assisted treatment providers, dentists, early childhood behavioral health providers and our county’s Women, Infants and Children team about their perspectives and hopes for clients. Every client has a treatment team, and each team member is only a few feet from my office door. I quickly realized the significant positive impact that close-quarters interdisciplinary collaboration has for many clients, and particularly those receiving medication-assisted treatment (MAT) and counseling services for substance use disorders.

MAT is a treatment model that lends itself to the integrated care setting. As described by the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT is the use of prescribed medications with concurrent counseling and behavioral therapies to treat substance use disorders. MAT is used in the treatment of opioid, alcohol and tobacco use disorders. The medications, which are approved by the Food and Drug Administration, normalize brain chemistry to relieve withdrawal symptoms and reduce cravings. MAT is not the substitution of one drug for another. When medications in MAT are used appropriately, they have no adverse effects on a person’s mental or physical functioning.

Medications used in MAT for alcohol use disorder include disulfiram, acamprosate and naltrexone. Those used for tobacco use disorders include bupropion, varenicline and over-the-counter nicotine replacement therapies. Medications used in MAT for opioid use disorders include methadone, buprenorphine and naltrexone — each of which must be dispensed through a SAMHSA-certified provider. Naltrexone is the only medication of the three that does not have the potential to be abused. Federal law mandates that those receiving MAT for opioid use disorder also receive concurrent counseling.

Embracing the advantages of integrated care

The combination of medication and therapy offers a holistic approach to treatment that is easily implemented in integrated care settings. The hope offered by the integration of services is embodied in an extraordinary case involving one of my clients who relapsed and arrived to counseling intoxicated, holding their chest. I was able to immediately consult with the client’s MAT provider, who ruled out the physical causes of chest pain after performing an electrocardiogram. Within 30 minutes, I was able to proceed with de-escalation of the client’s panic attack. The MAT provider educated the client on the next steps for care and on the dangers of using substances while taking MAT medications.

In a nonintegrated site, my only recourse would have been calling an ambulance for the client and a long wait at the hospital emergency room — and possibly a client who discontinued services. It is heartening when I can instead walk a client with symptoms of withdrawal across the hallway to the MAT provider or primary care provider, who can in turn offer targeted expert medical advice and medications to alleviate the symptoms.

Despite the substantial advantages that integrated care offers, however, most mental health and chemical dependency counselors are not adequately trained to provide effective counseling in integrated care settings for substance use disorders. In my experience, clients have better outcomes when receiving counseling services in conjunction with MAT. MAT alone can be effective, but the underlying thoughts and emotions that perpetuate use are not addressed unless concurrent counseling services are offered.

According to SAMHSA’s Treatment Improvement Protocol (TIP) No. 43, counseling for clients in MAT programs:

  • Provides support and guidance
  • Assists with compliance in using medications in MAT appropriately
  • Offers the opportunity to identify additional areas of need
  • May assist with retention in MAT programs
  • Offers motivation to clients

Although individual counseling is valuable, I am focusing on group counseling in this article because it offers similar benefits to individual counseling and is typically more cost-effective. In addition, TIP No. 43 notes that group counseling in MAT programs reduces feelings of isolation, involves feedback and accountability from peers, and enhances social skills training.

Resources for group counseling with MAT clients, or group counseling in integrated care settings, may not be easily accessible to many counselors-in-training or to practicing counselors. My goal is to share tips and resources with mental health and chemical dependency counselors that may be helpful in enhancing group counseling services for clients receiving MAT in integrated care settings. These tips and resources may also be useful to those providing group counseling services to MAT clients in settings that do not offer integrated care.

Tips and resources

1) Holistic education: MAT and integrated care are relatively new concepts for counselors, and we are still adapting. If it is new for us, it is new for our clients too. In the initial sessions of psychoeducational or process groups, the inclusion of education about MAT, the benefits of counseling in conjunction with MAT, and treatment in integrated care settings is essential.

Having access to a range of service providers is a benefit that clients should understand and utilize. Treatment team members can speak to the group about their role in client care and how their role may relate to the counseling group. For example, a dentist might help with appearance and self-esteem issues; an early childhood care provider might help the children of clients process situations arising from parental drug use; a primary care or MAT provider might link the client with hepatitis C treatment in addition to MAT. Such education can answer many questions that the group may have and help clients benefit from quality holistic care.

2) Dual licensure and continuing education: Many chemical dependency counselors refer out to mental health counselors and vice versa. In integrated care, it is ideal for counselors to be dually licensed. Dual licensure and training can assist counselors in identifying and addressing a variety of dynamics that may arise in group counseling with MAT clients.

For example, one client might have major depressive disorder and be using MAT for alcohol recovery, whereas another client might have symptoms of mania and be receiving MAT for opioid recovery. The way that counselors assist these clients may differ based on their knowledge of mental health diagnoses and the substance being used. Furthermore, counselors who are knowledgeable about these differing yet comorbid disorders will be better equipped to provide education to the group about the individualized and shared experiences of each member in recovery.

Some states have a combined mental health and chemical dependency counseling licensure board, whereas others have separate licensing boards. For more information about licensure, contact your state boards. If dual licensure is not plausible or desirable, I strongly recommended seeking continuing education in both mental health and chemical dependency counseling, as well as their relation to MAT.

3) Cognitive behavior therapy (CBT) and solution-focused brief therapy (SFBT) techniques: According to SAMHSA’s webpage about medication and counseling treatment, by definition, MAT includes counseling and behavioral strategies. The combination of MAT with these strategies can successfully treat substance use disorders.

One of SAMHSA’s recommended therapies is CBT, an evidence-based practice that has been shown time and time again to be effective in the treatment of substance use disorders. In an extensive review of the literature about the efficacy of using CBT for substance use disorders, R. Kathryn McHugh, Bridget A. Hearon and Michael W. Otto (2010) outlined a variety of interventions shown to be effective in addressing substance use disorders in both individual and group counseling. Those interventions included motivational interviewing, contingency management, relapse prevention interventions and combined treatment strategies.

Combined treatment refers to the use of CBT alongside pharmacotherapy, which includes MAT. Although some studies the authors reviewed indicated that MAT alone could be effective in treating substance use disorders, others demonstrated that combined treatment was most effective. Given SAMHSA’s recommendation, the literature review and my own personal experience, I believe that CBT may best benefit a group of MAT clients with substance use disorders in an integrated care setting.

Although CBT is suitable, I have learned that integrated care sites are much more fast-paced than the typical behavioral health counseling agency. Primary care and MAT appointments are as short as 15 minutes. In my work with our on-site behavioral health consultant, I noticed her quick and effective use of SFBT with individual clients. Although there is some research discussing the use and efficacy of SFBT in the treatment of substance use disorders, there is little information about using SFBT in groups with MAT clients in integrated care. This is a much-needed area for future research.

4) SAMHSA: SAMHSA has been mentioned various times throughout this article. That is a tribute to the value I place on the agency’s importance and usefulness. SAMHSA, in my opinion, is the best resource for exploring ways to enhance groups for clients receiving MAT. SAMHSA offers educational resources about a variety of substance use disorders; forms of MAT for different substances; comorbidities; and evidence-based behavioral health practices. SAMHSA is up to date, provides a variety of free resources for counselors and other professionals, and also has information about integrated care for professionals and clients.

According to SAMHSA’s TIP No. 43, groups commonly used with MAT clients include psychoeducational, skill development, cognitive behavioral and support groups. Suggested topics for individual counseling with MAT clients, which easily can be translated to group format, include feelings about coping with cravings and a changing lifestyle; how to identify and manage emergencies; creating reasonable goals; reviewing goal progress; processing legal concerns and how to report a problem; and exploring family concerns. Visit SAMHSA’s website (samhsa.gov) to enter a world of helpful information and resources for both personal professional development and client development.

5) Professional counseling organizations: Whereas SAMHSA offers information about substance use disorders, comorbidities, MAT, and individual and group counseling, the counseling profession’s codes of ethics and practice documents are crucial to the ethical provision of group counseling in this challenging field. Among the resources to consider are the 2014 ACA Code of Ethics, the Association for Specialists in Group Work (ASGW) Best Practice Guidelines (which clarify application of the ACA Code of Ethics to the field of group work) and the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling’s (ALGBTIC’s) competencies for providing group counseling to LGBT clients. ASGW also has practical resources to augment your group counseling skills through its Group Work Experts Share Their Favorite Activities series. Combining these resources with information acquired from SAMHSA and the tips in this article should prove helpful in designing and running effective groups for clients in MAT in integrated care settings.

Conclusion

As integrated care becomes more widespread, counselors must adapt their practice of counseling to the environment and to the full range of client needs. It is a counselor’s duty to utilize the benefits that integrated care has to offer, such as immediate and continual collaboration with treatment team members.

For clients in MAT, group counseling in integrated care can provide a multitude of benefits, including the opportunity to learn from each treatment team member, the opportunity to build community in the journey to recovery and accountability. To enhance group counseling in these settings, counselors might consider:

  • Including education from each service provider in the early stages of the group
  • Seeking dual licensure or relevant continuing education opportunities
  • Implementing theories that are suitable for the client issue and the setting
  • Using resources made available by SAMHSA and professional counseling organization such as ACA, ASGW and ALGBTIC

Implementing these tips and resources will result in a fresh and efficient group counseling experience for clients in MAT in integrated care settings.

 

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Stephanie Maccombs is a second-year doctoral student in the counselor education and supervision program at Ohio University. She is a licensed professional counselor and chemical dependency counselor assistant in Ohio. She has worked as a home-based addiction counselor and currently works in a federally qualified health center providing mental health and chemical dependency counseling services to adults participating in medication-assisted treatment. Contact her at sm846811@ohio.edu.

 

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Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Spinoza was right: Four steps to recovery from addiction

By James Rose August 21, 2018

The 17th-century Dutch philosopher Benedict Spinoza wrote that “when a man is a prey to his emotions, he is not his own master, but lies at the mercy of fortune.” He named this condition “human bondage.”

In my view, there is no greater form of human bondage among us now than drug addiction. Addiction is a form of self-imposed bondage that binds people as firmly as if they were held in chains. People who are addicted are being held in a form of bondage that is rooted in their own emotions.

In my three years of working with people in recovery from addiction, I have seen a clear pattern emerge. Individuals who begin recovery by detoxifying from their drug of choice soon feel a rush of hard emotions. These hard emotions are the ones they have been suppressing with their drug use.

From there, successful recovery follows a few distinct steps:

1) Patients name the emotions they are feeling.

2) They identify the story they have been telling themselves about the people, events or circumstances that are at the root of those hard emotions.

3) They examine the meaning of the story they have been telling themselves and consciously challenge that meaning.

4) They find a way to change the meaning of their story.

Because emotions flow from the stories we tell ourselves, patients in addiction recovery can then begin to change the emotions they feel, including the hard emotions that led to their drug use.

Let’s examine these four steps to recovery in detail.

1) Identify the hard emotions that arise. People vary significantly in their ability to discuss emotions. In general, women tend to be better at expressing their emotions than are men. Among people who abuse substances, both men and women typically struggle with expressing emotions. Not knowing how to handle strong emotions, and needing to numb them out, is often at the root of their use.

I often begin group counseling sessions by asking patients to name various emotions. It is a warm-up exercise to get them thinking about the range of emotions that exist and whether they are feeling them at that moment. Among the emotions frequently listed are loneliness, sadness, abandonment, depression, anger and hurt. Often, I will fill a chalkboard with their emotion words and then ask the participants to pick out a few words that apply to them. By giving patients a broad panoply of emotion words to choose from, they often find it easier to name their own emotions.

2) Identify the people, events or circumstances from which those hard feelings arose. For one young man, it was seeing his father, whom he considered his “rock,” suffer from diabetes and have his foot and part of his leg amputated. This was followed two years later by his father’s death. For a young woman, it was the death of her mother and the simultaneous abandonment by her boyfriend. For another young man, it was the emotional coldness of his father, which compelled him to threaten to commit suicide to get his father’s attention.

A sense of abandonment — and, in particular, abandonment in one form or another by a parent — plays a large part in many people’s addictions. A parent might be physically absent, either through death or divorce, or a parent might be physically present but emotionally absent. This can be the result of a parent who is simply emotionally distant by nature or a parent who is emotionally absent because they are involved in some form of addiction to drugs, alcohol, work, sex, gambling, pornography or other things.

Children by nature model themselves after their parents. Sometimes children are unaware of this modeling behavior. One client hated that his father struggled with alcoholism. So much so that this client had promised himself he would never drink alcohol, and he kept his promise. Instead, he used heroin. He had simply replaced one addiction with another, becoming as emotionally unavailable to others as his father had been to him. One common element among all addictions is that they make a person emotionally unavailable to others around them.

Sometimes I use the analogy of fun-house mirrors — those mirrors they sometimes have at carnivals that distort people’s images. As children, we try to get a clear picture of who we are by the image we see reflected in the eyes of our parents. If a child is fortunate enough to have mature, healthy parents, that child is more likely to gain a reasonably accurate self-image from their parents and have a secure emotional foundation from which to face life.

But if a child’s parents are unhealthy or immature, then the self-image the child receives from those parents is more likely to be distorted or flawed. These children may go through life with the unsettled sense that there is something wrong with them. The grown child then lacks a basis for determining what his or her self-image should be.

That sense of not being able to see oneself clearly can create a lasting pain in a child’s heart, and addictive behaviors are more likely to develop in an effort to numb out that pain. As counselors, our work can involve “reparenting” our clients by providing a clear self-reflection of who they truly are — an image these clients might never have received from their actual parents.

There is also a hidden stigma involved in situations in which children have the opportunity to become better than their parents. Sometimes this stigma is called invisible loyalty. For example, if a child comes from a family where drinking is normal behavior, the child risks breaking a family norm — and thus becoming “better” than his or her parents — by not drinking. That is a step toward independence that not everyone is willing to take.

3) Challenge the story you are telling yourself. Often, the event or circumstance involved in the triggering event creates a terrible blow to the person’s self-esteem. For example, the client whose father walked out on the family when the client was 5 was taught in the most unmistakable terms that he was worthless. The woman whose mother died and whose boyfriend left her shortly thereafter simultaneously suffered both grief and abandonment — abandonment at a moment in her life when she most needed someone she could turn to and trust to help her deal with her grief. The young man who lost his father to diabetes felt cast adrift without the man who had represented stability in his life.

Our emotions follow our narrative. If the stories we tell ourselves are ones of loss, abandonment and aimlessness, our feelings will be ones of worthlessness. It is that feeling of worthlessness at the core of our being that is often at the root of addiction. Addiction is a way of trying to numb out those unbearable feelings. If our narrative tells us that all is lost, then there is nothing much to do but to numb out our pain and drag ourselves through life as best we can.

Our feelings are predictions of what to expect, based on our past experience. If our past experience has been full of sorrow and loss, we will come to expect more sorrow and loss in our lives. We will approach the potential of something joyful happening in our lives with dread, lacing it with the expectation that, sooner or later, things will turn out badly. If close relationships turn into abandonment and loss, we might create self-fulfilling expectations by not entering into new relationships with openness.

And yet, it is human nature to want to have close relationships. One young man with whom I worked desperately wanted to feel some sort of emotional connection with his father. To all appearances, his father was a good man and a good father, but he was incapable of showing warmth and caring to his son on an emotional level. The son’s drug use was an attempt to self-medicate the pain he felt at the lack of that important connection in his life.

It reached a point where the son called his father and said he had a knife in his hands and was ready to slit his wrists because he was so desperate for his father to show some level of care and concern for him. The father responded; the son did not commit suicide. He told his father of his drug use, and the son agreed to go into recovery. The son had received a message of worthlessness from his father, and he found that message too painful to live with. He forced his father’s hand to show caring.

In recovery, the young man gained an understanding of how deeply he felt the sense of emotional abandonment by his father. Once he gained an understanding of that emotion, he was ready to pursue the fourth step.

4) Change the way you tell your story. For that young man, recovery meant telling his story differently. Instead of telling himself that his father’s coldness meant he was worthless, he came to understand that his father’s coldness was his father’s nature — the product of his father’s own difficult upbringing. The son learned that he was capable of finding the sort of emotional connection he craved with his mother, his siblings, his friends and his new companions in Alcoholics Anonymous (AA).

He came to accept that he would never change his father, but he learned that he could change himself so that he could find the emotional gratification he longed for from others. He had previously believed that he needed to be like his father — cold and emotionless. Once he changed his story and gave himself permission to truly feel the emotions he was experiencing, he could share those feelings with others and find the sort of emotional connections that he craved. Once those emotional longings were satisfied, his need to numb out his more painful emotions evaporated.

Changing one’s story is fundamentally an act of building self-esteem. Self-esteem is built in a number of ways. It comes from allowing oneself to feel one’s emotions, from avoiding all-or-nothing thinking and from recognizing that life events most often consist of shades of gray. Finding the strength to express one’s true self among others, and to experience that self as different from other people and to develop enough detachment to become comfortable with those differences, is also essential.

For some people, and particularly those who had difficulty with their parents while growing up, spirituality may provide the context for seeing themselves differently. This is the concept behind the step in AA to surrender to a higher power, however that higher power may be understood. Seeing oneself as a child of God may provide a corrective lens for those who grew up with the fun-house mirrors and were never able to gain a true picture of themselves through the eyes of their parents.

I once spoke at a Christian-based recovery center where I offered that sort of corrective vision to the patients by slightly changing the word order of a familiar Scripture reading. I told the audience, “If you want to know who you are, consider these words from the Gospel of Matthew. ‘You are blessed, you who are poor in spirit, because yours is the kingdom of heaven. You are blessed who mourn, for you shall be comforted. You are blessed who are meek, for you shall inherit the earth,’” and so on through the remaining Beatitudes. And then I said, “You are a child of God, because why else would Jesus have taught us to pray to God as ‘Our Father?’”

Learning to see oneself differently, and changing one’s story in a way that builds self-esteem, is the fundamental act of recovery. Guiding patients through the growth of creating a healthy sense of self-esteem is at the core of my work as a counselor. People are not only recovering from the habit of substance abuse. They are recovering their lost selves.

Spinoza wrote, “The more clearly you understand yourself and your emotions, the more you become a lover of what is.” Examining emotions with patients and helping them to see themselves as they truly are is the royal road to helping those in recovery. It is the path that leads them to self-knowledge and self-esteem. Ultimately, it is the path out of the trap of human bondage.

 

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James Rose, a national certified counselor and graduate professional counselor, is a recent graduate of Loyola University Maryland and works in addictions treatment at Ashley Addiction Services. Contact him at jrrose@loyola.edu.

 

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Read more by James Rose, from the Counseling Today archives: “Stepping into recovery

 

Related reading, also from Counseling Today: “Grief, loss and substance abuse

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Addicted to sex?

By Amanda L. Giordano and Craig S. Cashwell August 7, 2018

Sex and sexuality are necessary, healthy and, arguably, sacred aspects of the human experience. What happens, though, when sex is used not to enhance intimacy and connection with others but, rather, becomes out of control? What happens when a person describes a clear set of personal values around sexual behavior yet consistently crosses his or her own boundaries and compromises personal sexual values? What happens when a person continues a pattern of sexual behavior despite detrimental consequences? Can a person be addicted to sex?

Although most forms of sexual expression are healthy, the sex addiction model posits that some individuals may develop compulsive, dependent relationships with sex. Critics of the sex addiction model suggest that the addiction label pathologizes nonnormative sexual behaviors (e.g., fetish, kink), yet true proponents of the model do not claim to define morally appropriate forms or frequencies of sexual acts. The focus, rather, is on one’s relationship with sex.

Just because a sexual behavior violates an individual’s personal values, religious or spiritual beliefs, or societal norms does not make it an addiction. Instead, sex addiction has specific defining characteristics:

  • Loss of control
  • Continued engagement despite negative consequences
  • Mental preoccupation or cravings

Thus, rather than being sex-negative, advocates of the sex addiction model work to identify those who are unable to control their sexual behavior, are experiencing distressing outcomes and are mentally preoccupied or craving sex. Once sex addiction is determined, individuals then can get the treatment and support they need to establish healthy sexuality. 

A topic for debate

The notion that sex can be addictive still is debated among mental health professionals. Instead of addiction, alternative explanations for problematic sexual behaviors include impulse-control issues, obsessive-compulsive disorder, neuroticism, learned behavior, a form of sensation seeking, internalized sex-negative messages or manifestations of a mental health issue such as bipolar disorder.

The addiction model, however, purports that the primary issue is an out-of-control relationship with sex resulting from changes in chemical messengers in the brain. Specifically, naturally reinforced behaviors, such as eating and sex, are linked to the release of neurotransmitters (i.e., dopamine) related to pleasure and reinforcement. A naturally rewarding behavior such as sex can become a supernormal stimulus leading to dysregulation in the dopaminergic system. The resulting neuroadaptations affect reward, memory, attention and motivation. Thus, from an addiction model perspective, sex can hijack the natural functioning of the reward pathway in some individuals, leading to addictive behavior.

The sex addiction model contends that in addition to being positively reinforcing through the release of dopamine and other neurotransmitters, sex can be negatively reinforcing. Over time, sex can become addictive when it is used as the primary or, sometimes, sole method of regulating undesirable emotions. In other words, sexual behavior can be negatively reinforcing when it functions as an avoidance strategy and is used to escape emotional pain. In a negative feedback loop, however, the individual often feels shame as a result of his or her out-of-control sexual behavior. Paradoxically, this shame may become part of the undesirable emotions that the person then strives to regulate through sexual acts. From an attachment perspective, it is likely that these individuals never learned to coregulate emotionally and, instead, try to autoregulate emotions.

Scholars who primarily emphasize the negative reinforcement of sexual behavior often argue for terminology other than sex addiction, such as compulsive behavior or hypersexuality. However, the fact that sex provides both negative reinforcement (i.e., escape) and positive reinforcement (i.e., pleasure) seems to give credence to the addiction model.

Although controversy remains, the mental health field is steadily embracing the notion that behaviors can become addictive. For example, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) included the diagnosis for gambling disorder in a chapter titled “Substance Use and Addictive Disorders.” In addition, internet gaming disorder and nonsuicidal self-injury (which some conceptualize as a behavioral addiction) were included in Section III as conditions in need of further study.

A diagnosis of hypersexual disorder was considered for the DSM-5 but ultimately was not included. The American Society of Addiction Medicine, however, revised its official definition of addiction to include both chemicals and naturally reinforcing behaviors. Furthermore, within the World Health Organization, the Working Group on Obsessive-Compulsive and Related Disorders for the 11th version of the International Classification of Diseases has recommended a diagnosis of compulsive sexual behavior. The organization determined the need for additional research to classify sexual behavior as addictive but clearly recognizes that out-of-control sexual behavior is a public health issue.

In addition, the recent surge of public concern related to pornography use and related erectile dysfunction among relatively young men (as evidenced by high traffic on websites dedicated to helping individuals “reboot” or discontinue use of pornography) has contributed to the influx of neuroimaging studies exploring addiction to pornography. Researchers have confirmed that the same regions of the brain activated by drug stimuli also are activated by online sexual stimuli and that addictive sexual behavior may be associated with decreased gray matter and diminished connectivity in the brain.

Types of sex addiction

Scholars conceptualize two types of sex addiction. The profile for the classic type includes early attachment wounds, family-of-origin issues and trauma histories, culminating in insecure attachment strategies in adulthood. Research shows a clear link between problematic sexual behavior and insecure attachment styles, and the majority of individuals in treatment for sex addiction have experienced trauma. For individuals with classic sex addiction, their sexual behavior may have been a primary means to fulfill attachment needs or escape emotional pain. Over time, however, the behavior became compulsive and out of control as the natural longing for sex became a need and then an addiction. 

Recently, a second contemporary type of sex addiction has been identified among individuals without the classic profile of trauma or attachment wounds. Instead, the contemporary type emerges as a result of chronic, excessive exposure to sexual stimuli, especially in the form of pornography or cybersex, made more readily available when the internet became ubiquitous. Sex researcher Alvin Cooper referred to cybersex as a triple-A engine, offering affordability, anonymity and accessibility to users.

Online sexual images and videos are pervasive, and current estimates suggest that the average age of first exposure to pornography is 11. This initial exposure is often accidental on the part of the child, with pornography sites known to purchase domain names of commonly misspelled children’s websites (referred to as cybersquatting). Over time, however, pornography becomes a supernormal stimulus reshaping the brain by repetitive experiences of pleasure associated with online sexual images. The brain responds to this hyperactivity in the reward pathway by decreasing natural dopamine production and receptors. Consequently, with decreased natural dopamine production, those with sex addiction may feel mildly depressed at baseline, inducing cravings for sexual behavior to alleviate the negative mood. Thus, whether classic or contemporary, sex addiction leads to changes in brain circuitry, which, in turn, perpetuates the addictive cycle.

The nature of sex addiction

Among individuals for whom sex has become addictive, the condition is all-consuming. When those with sex addiction are not engaging in sexual behaviors (acting out), they likely are thinking about them (fantasy and mental preoccupation), getting ready for them (preparation and ritualization) or recovering from the consequences (physically and emotionally).

Sensitization caused by neuroadaptations may lead individuals to seek novel or more intense sexual stimuli to achieve the desired effect (otherwise known as tolerance). For example, an individual may shift from nonviolent to violent pornography or change from streaming cybersex to partnered anonymous sex. Those with sex addiction begin to live a double life as they hide their out-of-control sexual behaviors from others, withdraw and isolate. Furthermore, many people with sex addiction lose sexual interest in their romantic partners and experience sexual dysfunction because of classic conditioning in which arousal is paired with alternative stimuli such as a computer. The addiction affects the individual physically, psychologically, spiritually, relationally and emotionally. Although sex addiction begins to control these individuals’ lives, they often are reluctant to tell anyone about their experience because of intense feelings of shame and self-loathing.

Addictive sexual behavior can manifest in a variety of ways, from compulsive masturbation, anonymous sex and prostitution to compulsive sexual relationships, voyeurism or rape. Indeed, some sexual acting-out behaviors can cross the legal line and fall into the realm of sexual offenses, but the majority of those with sex addiction do not offend; rather, they engage in legal forms of compulsive sexual behavior.

Sex offenders generally have distinct profiles from sex-addicted nonoffenders. Specifically, sex offenders are more impulsive; engage in more intrusive behaviors; respond to offenses with hatred, anger and entitlement; and have low remorse. This profile differs from the progressive trajectory of sex addiction that tends to include more frequent, yet less intrusive, acting out; triggers shame, despair and powerlessness; and is met with high remorse. When sexual acting-out behaviors cross the line of legal offense, those who are sexually addicted are legally responsible for the consequences of their actions despite having an addiction (much like someone with alcohol addiction who injures another person while driving under the influence).

Although individuals with addiction are not responsible for “giving themselves” sex addiction, they are responsible for their recovery through seeking help and working a treatment program. Increasing public awareness about sex addiction can help promote early access to professional treatment, with the hope being that this step will aid in avoiding decades of negative consequences both for individuals with sex addiction and for others who may be affected.

Clinical considerations

Given that sex addiction can include myriad sexual behaviors, it is important for clinicians to assess and screen appropriately. Most sex addiction emerges in late adolescence and young adulthood, so school counselors and community clinicians working with young clients can provide early intervention by regularly screening for sex addiction. Counselors are encouraged to broach the subject of sex in counseling and explore clients’ relationships with their sexual activities, such as masturbating, sexting, hooking up, using pornography, engaging in cybersex, using sexual apps and engaging in compulsive sexual relationships.

Despite the fact that sex addiction emerges early, most individuals do not seek professional treatment until later in life as a result of experiencing often extreme negative consequences (i.e., “hitting rock bottom”). Accordingly, all clinicians should be screening for a loss of control over sexual behaviors, continued engagement in sexual behaviors despite negative consequences, and mental preoccupation or cravings. Along with informal screening and exploration, many formal assessments for sexual compulsivity and addiction exist, including the Sexual Addiction Screening Test, the Sexual Compulsivity Scale and the Sexual Dependency Inventory. The use of these instruments can help clinicians better understand their clients and coconstruct appropriate treatment goals.

Once counselors identify the presence of sex addiction, they have many tools and treatment programs to assist in helping clients reach long-term recovery. Unlike recovery from chemical addictions, the goal of sex addiction treatment is not abstinence from all sexual acts, but rather the development of healthy sexuality. It is the compulsive, detrimental sexual behavior that counselors and clients work to eradicate.

To help clarify recovery from sex addiction, many clinicians and 12-step recovery programs (such as Sex Addicts Anonymous) use the three-circles activity. With a sponsor or counselor, those with sex addiction draw three concentric circles. In the innermost circle, the client lists all unhealthy sexual behaviors that have led to negative consequences and over which the individual has lost control. These are the behaviors from which the client is choosing to abstain.

In the middle circle, the client lists behaviors that may lead to sexual acting out. Identifying middle-circle behaviors is important from a neurological perspective. The amygdala is responsible for emotional memory; thus, it remembers stimuli associated with the experience of pleasure. After years of sex addiction, individuals likely have associated specific locations, sounds, sights, smells and actions with sexual pleasure. The middle circle, therefore, includes any stimuli, such as excessive fantasizing, cruising or sexually objectifying others, that may trigger the amygdala and lead to sexual craving.

Finally, the client uses the outermost circle to identify healthy behaviors that will support the individual’s recovery. These behaviors might include participating in 12-step groups, engaging in counseling, fostering spiritual practices, exercising, eating healthy, keeping home and work spaces nonchaotic, spending time doing recreational activities and increasing healthy social support.

Many counseling approaches and interventions, including cognitive-behavioral approaches, psychodynamic approaches, acceptance and commitment therapy, motivational interviewing, art therapy, group counseling, couple and family counseling, and even psychopharmacology, are appropriate for work with sex addiction. It is important to note that recovery from sex addiction often spans years rather than months. Clients, family members and partners may erroneously believe that recovery occurs within a matter of weeks and can become disheartened when initial attempts to change behavior are unsuccessful. Providing psychoeducation about the neurobiology of sex addiction can offer a more accurate perspective and create realistic expectations. Clients can find hope in the fact that, in time, the brain can heal and resolve dysregulation in the reward circuitry. This healing process takes time, however, and the completion of specific tasks such as those outlined in Patrick Carnes’ 30 tasks of recovery.

Additionally, sex addiction may not be the only concern addressed in treatment. Given the common mechanisms underlying addiction, it is not surprising that coaddictions to gambling, food, gaming, the internet or substances often exist among those with sex addiction. Furthermore, research supports the prevalence of comorbid mental health problems, including bipolar disorder, major depressive disorder and attention-deficit/hyperactivity disorder, among those with sex addiction. Finally, a trauma-informed perspective may be necessary to help clients resolve trauma to improve emotion regulation.

Clinicians should take an integrated approach to address all addictive and mental health concerns in treatment. Integrated care may be more complex than addressing one concern at a time, but diverse treatment teams, supplemental or adjunct resources, and holistic recovery plans can best help clients reach long-term health and wholeness.

Advocating for clients

One of the most necessary forms of advocacy for this population is increased awareness related to sex addiction. During the Masters Tournament in 2010, roughly six months after the story broke concerning Tiger Woods’ sexual behavior and treatment for sex addiction, someone flew a plane over the Augusta National Golf Club with a banner reading, “Sex addict? Yeah. Right. Sure. Me too.”

It is inappropriate for anyone outside of Woods’ personal and professional circle to try to determine a clinical diagnosis for his case, but the plane and banner reflect a popular public sentiment: Sex addiction is not real. Advocates can work to increase public knowledge relating to sex addiction and dispense critical research about the condition.

Additionally, mental health professionals can take several practical steps to advocate for clients who are sexually addicted. Currently, many counseling centers do not include information about sex addiction on their websites or relevant items on their intake forms. This lack of acknowledgment may inadvertently communicate to clients that sex addiction is not an appropriate topic for counseling. Thus, one of the simplest forms of advocacy is to include the experience of compulsive sexual behavior on websites, advertisements and client intake forms.

Another important advocacy effort is to acknowledge that individuals of all genders can have sex addiction. Specifically, when community groups, media spokespeople or well-meaning educators leave women out of the conversation about addiction to sex or pornography, they add a layer of stigma for these individuals. Although prevalence rates may differ among genders (about 1 in 7 of those with sex addiction are women), it does not discount the salience of sex addiction among female populations.

Finally, the most recent standards of the Council for Accreditation of Counseling and Related Educational Programs require educators to teach students about theory and etiology of addictive behaviors. Therefore, counselor training programs can advocate for future clients by infusing relevant, up-to-date information regarding sex (and other behavioral) addictions in the counseling curriculum.

Conclusion

Much work is needed to decrease the stigma and shame associated with sex addiction. Although stigma exists with any addiction, it seems particularly poignant with regard to compulsive sexual behavior. In the cycle of sex addiction, shame serves as both a precursor and a consequence of sexual acting out. Raising public awareness regarding the nature of sex addiction can help combat this shame.

Rather than conceptualizing compulsive sexuality as a moral failing, the addiction model provides a framework to empower clients to manage their condition while offering effective tools for recovery. Controversy may always exist regarding the conceptualization of sex addiction, but it is imperative to continue the conversation, increase empirical evidence and engage in advocacy efforts to serve and support this population.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Amanda L. Giordano is an assistant professor at the University of Georgia. A licensed professional counselor, she specializes in addictions counseling and multiculturalism. Giordano serves on the executive board for the Association for Spiritual, Ethical and Religious Values in Counseling and the editorial review boards for the Journal of Addictions & Offender Counseling and Counseling and Values. Contact her at amandaleegiordano@gmail.com.

Craig S. Cashwell, a professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro, is an American Counseling Association fellow. Additionally, he maintains a part-time private practice focusing on couple counseling and addictions counseling. He serves as editor-in-chief of Counseling and Values.

 

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Stepping into recovery

By James Rose June 13, 2018

After many years of working as an accountant, I decided to enter counseling as a profession in my “retirement” years. After four years in graduate school, including two years of clinical work at an addictions recovery center, I began my new professional career this past January. Here is how it began.

 

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It was my third day as the evening counselor at Ashley Addiction Services. A clinical aide called me and said, “We have a patient here who wants to leave now. He’s calling his girlfriend to get a ride, and he is looking for someone to punch so he can get kicked out. Would you come down?”

The patient was a young man I had met during my training period the prior week. “You look stressed,” I said.

“Of course I’m stressed!” he screamed back.

I coaxed him out of the clinical aide’s office to a quiet place where we could talk. He told me he was on the withdrawal drug Suboxone. He wanted to go out and get high, then quickly get enrolled in another facility so he wouldn’t disappoint his mother.

“Your mother’s opinion is important to you,” I said.

“Of course,” he said.

“What about your dad?” I asked.

“He’s dead,” he told me.

I asked him to tell me more. He had been using for seven years. This was his fourth stay in a recovery facility.

“What happened seven years ago?” I asked.

“Nothing,” he said.

“When did your dad die?” I asked, following a hunch that there might be a link.

“Five years ago,” he said.

No link, I thought.

I had been working in addictions recovery for two and a half years at that point. I spent most of my life as an accountant, working in grants administration at various universities. At age 58, I had a near-fatal heart attack, and during my recovery, I knew that I had to change course in my life. Counseling had always fascinated me, and I had been in and out of therapy myself for about seven years. I made the decision six months after the heart attack to make a major course change in my life and study counseling. I enrolled in the pastoral counseling program at Loyola University Maryland, the same school where I had earned a Master of Business Administration 26 years earlier.

As part of my counselor training, I had worked as an addictions counselor at the Westminster Rescue Mission. I remembered a story about another patient I had worked with there who reminded me of my current patient. I shared that story with my current patient, explaining that my former patient’s parents divorced when he was 5. His dad lived only a few blocks away after the divorce, but he rarely saw his dad. Sometimes his father would tell him he would take him fishing on a Saturday morning, so this young boy would get up early, get dressed, assemble his gear and wait all day at the living room window for his dad to come. His father never came.

My former patient started shooting heroin when he was 18 and continued to do so for the next 24 years. After working with this patient for a year, he said to me, “Until we talked, I never understood the connection between what my father did and my addiction.”

Something in this story seemed to resonate with my current patient. So I asked him again, “What happened seven years ago?”

“That was the year my dad got sick,” he said. “He got diabetes and had to have his foot amputated. He was my rock.”

And then it hit him: the link between his dad’s sickness and death, and his own addictive behavior. He jumped out of his chair, threw his arms around me and shouted, “You just saved my life!”

I breathed a sigh of relief. It was a heady moment for me. We both knew an important bridge had been crossed. We talked a little while longer, then went for a quiet walk outside.

 

An epidemic of loneliness

People talk of the tragedy of the opioid epidemic. And the tragedy is painfully real. One of my patients lost two friends during his first weekend in recovery, and he believed that if he had not come in for help, he too would be dead. Another patient found his best friend dead from the dope he had shared with him. A third patient stood before the entire patient community and told us that he had lost 42 friends to overdoses in one year, and he knew that if he did not come in for help, he might well be next.

And yet from my perspective of working with people in addiction, the opioid epidemic masks a deeper epidemic. The epidemic I see every day is an epidemic of loneliness.

It is so ironic. We have never been more connected. We have cell phones, email and FaceTime. We can meet anyone, anytime, anywhere. The world I live in today reminds me of the futuristic world I saw pictured in science fiction comic books when I was a kid. And yet, rather than being more connected, we seem more distant from each other than ever before.

I believe that we all need a deep sense of connection with other people in our lives. Emotional connection is an essential part of being human.

People in recovery are in a state of inner conflict. They simultaneously want to recover and stop abusing drugs and alcohol, while at the same time they have cravings to continue to use. When they stop using, once they get through the painful physical symptoms of detoxifying, the painful emotions that led them to use in the first place tend to rise to the surface. Often, there is a painful event or painful circumstance in their lives that caused them to use in the first place.

Substance abuse is often a coping strategy, a way of easing pain, and very often it is some painful event that triggered their addiction. Substance abuse serves a function in their lives; it reduces their pain enough to enable them to cope and carry on with their lives. In that way, it is similar to taking a pill to get rid of a headache. Of course, the circumstances are far more drastic.

I asked one user why he used heroin, and he said it was better than committing suicide. It was hard for me to argue with his logic. From his perspective, heroin use had the positive aspect of keeping him alive, of keeping him from killing himself by his own hand. That is part of the reason that it is so hard for people to give up their addiction. It serves the positive function in their lives of keeping them alive, allowing them to continue to function, in spite of their pain. It numbs out their pain, however temporarily.

Unfortunately, in numbing out their pain, it numbs out all of their other emotions as well. This is why it is nearly impossible to have a meaningful relationship with someone who is addicted to a substance. Meaningful relationships require an emotional connection. How can one have a meaningful connection with someone whose emotions are chronically numbed out?

 

Breaking the cycle

The damage of addiction spreads out like the ripples in a pond, far beyond the individual who is addicted, to affect all the other people in that individual’s life — friends, family members, co-workers. Children of parents who are addicted grow up with parents who are emotionally unavailable. These children’s lives are shaped by the experience of emotional unavailability, and so the cycle continues.

Breaking that cycle of emotional absence is at the heart of the work I do. When patients stop using, the emotional pain that led them to use in the first place reemerges, and they often are as unequipped to deal with that pain in the present as they were in the past. As their counselor, I help patients to identify past trauma and try to find a new perspective through which to see it.

One way of looking at emotions is to think of them as predictions of what is about to come. If you enter a house filled with the aroma of freshly baked chocolate cookies, you might find your mouth starting to salivate and your stomach starting to rumble — physical signs that your body is preparing for you to eat something yummy. A sudden scream in the night might make your body straighten, your muscles tense, your eyes widen and your ears perk up — all signs that your body has gone into a high state of alert for possible danger, usually accompanied by a sharp rush of adrenalin to be ready for fight or flight. Again, these are the physical signs of anticipation of and preparation for predicted danger.

Emotional pain evokes different bodily reactions. We may feel a loss of appetite, a heaviness of heart and a wish to isolate. The triggers for emotional pain may be less obvious to a person than is the smell of cookies or a scream in the night, but they are certainly quite real to the person experiencing them. And the pain can be overwhelming.

This is where substance abuse comes into play. Often, emotional pain comes about when a person has lost someone with whom they had an important emotional connection in their life, and that emotional connection has been broken. If a parent has died or moved away, a loved one has betrayed you or a traumatic event such as a rape or murder has occurred, there is no way to undo the event. The pain of such events can be overwhelming.

Drink or drugs can provide a means of easing the pain enough that the suffering person can get on with their lives, but they cannot undo the event. Many people find solace over time and find ways to cope with the pain without resorting to drink or drugs; however, many do not. Because drugs numb the pain without addressing the loss, a person remains stuck within the loss, and so the need for the drug endures.

The damaging paradox of a person who uses drugs to deal with the loss of emotional connection is that drugs eliminate the possibility of creating new emotional connections, which are the very thing the person needs to heal. Drugs numb out all emotions — both the painful and the joyful ones — and without the ability to feel the full range of emotions, any new, real emotional connections are impossible to create.

 

Searching for ‘meaning’

Being with a person in the initial stages of recovery from substance abuse is an awesome experience. As a counselor, I face them in that moment of transition in their life. I know I cannot fix or heal anybody. The thing I can do is to be present with them, offering what guidance and presence I can as I try to help them find healing within themselves.

Often, that is a matter of helping them name and identify those hard emotions that arise within them — the ones that led to substance use in the first place. Once the emotions are identified, then we look for the event or the circumstance in their life that brought that emotion into play. This is the moment when the hard stories come out, the stories of heartache and loss. And then it is a matter of looking at the meaning those stories have had in their lives.

It is the meaning we place on our stories that give them their emotional charge. A child whose parents divorced and whose father moved away might, as a child, believe in some unnamed way that they are worthless. After all, dad delivered the message, in the most obvious way possible, that they were not worth sticking around for. I have known many people struggling with addiction who had just that circumstance in their lives, and that sense of worthlessness was at the root of their addiction.

In this work, we can look at stories like that and change the meaning. The meaning might be that dad was a troubled man. It might be that dad and mom had a bad marriage and their breakup was necessary. It might be that dad had to go away on a job or for military service. By reframing the story, we can change the meaning, and when we change the meaning, the emotions that accompanied that story can change.

This was the case for the young man whose story I shared at the beginning of this article. For him, the meaning of his dad’s sickness and death was that he was losing his rock, and there would be no one there to give him guidance. His story changed to dad was sick and died through no fault of his own, nor by his father’s choice, and now he would have to find his own guidance. In changing the meaning of his story, his emotions changed, and his need to numb out his painful emotions with drugs gradually evaporated.

 

Being present

So, at the heart of my work is the aim of being present with another person so that they can learn to be emotionally present themselves. One of my favorite outcomes was when a patient told me about his 17-year-old daughter. She was the rock of their family, a straight-A student who was always reliable and dependable, emotionally calm and stable.

She came to visit her father a few weeks after he had entered recovery. He told me he could not believe what had happened. His strong, calm and rational daughter had broken down in tears in front of him. I said, “She was emotionally present with you.” After a moment, I asked, “Do you understand why?”

He looked baffled and said, “No.”

I said, “For the first time since she was a little girl, she could sense that you were emotionally present for her, no longer drunk or high, but really right there with her. She felt it, and so she, for the first time in years, was able to be emotionally present with you. That is why she cried.”

My final meeting with the young man whose father had died of diabetes was the night before he completed the program. He told me that he was planning to move back home where he could help his mother. He expected he would be able to go back to work at his job in a restaurant, and he planned to attend school in the fall. I asked what he would study, and he said he was interested in psychology. He said he was thinking of becoming a counselor, which would further motivate him to stay on his path of recovery.

I saw him again the night he finished the program. I was thinking of the years I had spent in grad school — the books I had read, the papers I had written, the checks I wrote and all the time I had invested. And in a moment, it was all worthwhile when he threw his arms around me and said, “Thank you.”

 

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James Rose, a national certified counselor and graduate professional counselor, is a recent graduate of Loyola University Maryland and works in addictions treatment at Ashley Addiction Services. Contact him at jrrose@loyola.edu.

 

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